Le glycopyrrolate a dtd ndcessaire chez 11 patients sur 20 dans la groupe sufentanil et ... succinylcholine 1 mg. kg -j following topical spray with lidocaine 4%.
220
Epidural lidocaine with sufentanil and epinephrine for abdominal hysterectomy under general anaesthesia: respiratory depression and postoperative analgesia The purpose of this investigation was to compare the analgesic actions and side-effects of a 50 lzg epidural bolus of sufentanil and 50 I~g epinephrine, with a control group receiving saline and epinephrine. The method employed was a prospective, randomised, double-blind trial involving 40 ASA I or H patients for total abdominal hysterectomy. All received 1.5% lidocaine with 1/200,000 epinephrine epidurally before operation, until a block to T4 was established. Patients were anaesthetised, their tracheas were intubated, and they were allowed to breathe spontaneously before administration of the test drug. Results showed that sufentanil prolonged the duration of local anaesthesia (198 +--35 min vs 174 +- 29 rain; P < 0.05), and of analgesia (288 --+85 rain vs 188 +...42 min; P < 0.01). There was an increase in somnolence in the sufentanil group (9/20 vs 2/20; P < 0.05). Glycopyrollate was given to 11/20 patients in the sufentanil group vs 1/20 in the control group (P < O.01) following bradycardia and hypotension. Clinical respiratory depression occurred in the sufentanil group; 5/20 patients required controlled ventilation following apnoea >20 sec. It is concluded that epidural sufentanil causes considerable cardiorespiratory
Key words ANAESTHETICTECHNIQUES:regional, epidural; ANALGESICS: sufentanil; VENTILATION:apnoea, failure. From the Department of Anaesthesia, Groote Schuur Hospital and University of Cape Town, Observatory, 7925, South Africa. Address correspondence to: Dr. R.A. Dyer, Department of Anaesthesia, Groote Schuur Hospital and University of Cape Town, Observatory, 7925, South Africa. Accepted for publication 4th November, 1991.
CAN J ANAESTH 1992 ! 39:3 / pp220-5
Robert A. Dyer FFA(SA), Kevin Camden-Smith FFA(SA), Michael F.M. James PhD
depression in the setting of general anaesthesia, and should be used with caution in the spontaneously breathing, anaesthetised patient. Le but de cette investigation dtait de comparer l' analgdsie et les effets secondaires obtenus suite ~ un bolus dpidural de 50 i~g de sufentanil et de 50 l~g d'dpindphrine, fi un groupe contr8le recevant du salin et de l'dpindphrine. Cette dtude prospective, au hasard et dl double insu, impliquait 40 patientes ASA I ou 2, devant subir une hysMrectomie abdominale totale. Avant la chirugie, un bloc dpidural dtait dtabli au niveau T4 ~ l'aide de lidoca~ne 1,5% et d'dpindphrine, 1/200 000. Par la suite, les patientes dtaient anesthdsides, une intubation endotrachdale rdalisde, et le mddicament ~ dvaluer administr# apr~s la reprise de la ventilation spontan#e. Les rdsultats ont ddmontrd que le sufentanil prolongeait la durde de l' anesthdsie locale (198 +- 35 rain vs 174 +- 29 min; P < O,05), et de l' analgdsie (288 +- 85 rain vs 188 --+42 min; P < 0,01). II y avait une augmentation de la sommolence dans le groupe sufentanil (9/20 vs 2/20 ; P < O,05). Le glycopyrrolate a dtd ndcessaire chez 11 patients sur 20 dans la groupe sufentanil et chez 1 pateinte sur 20 darts le groupe contr~le (P < 0,01) suite ~ une bradycardie et ~ une hypotension. Une ddpression respiratoire clinique est survenue dans le groupe sufentanil : 5 patients sur 20 ont eu besoin de ventilation conMl~e suite ~ une apn~e de plus de 20 secondes. En conclusion, le sufentanil dpidural provoque une d#pression cardiorespiratoire considdrable dans le contexte d'une anesthdsie gdndrale, et devrait ~tre utilisd avec prdcaution chez le patient anesthdsM et en ventilation spontande.
Epidural anaesthesia in combination with a light general anaesthetic is a well-accepted technique for gynaecological procedures. The combination of epidural opioids with local
Dyeretal.:
EPIDURAL SUFENTANIL
anaesthetics is a frequently employed method of postoperative analgesia.l Hydrophilic opiates such as morphine may be associated with late respiratory depression when administered epidurally, and their use requires the presence of adequate monitoring for 24 hr in a high-dependency unit. 2'3 Sufentanil, a potent lipid soluble opiate with high i9 receptor affinity, has been employed in several recent studies on postoperative analgesia following abdominal surgery. 1'4'5 Analgesia is rapid in onset and of two to six hours duration following 50 to 75 I~g epidural sufentanil in abdominal surgical cases. L4,6The addition of epinephrine may prolong the effect.7 Though there have been no reports of delayed respiratory depression following epidural sufentanil, evidence of early respiratory depression remains controversial.3 No previous studies have examined the interaction of epidural opiates and general anaesthesia on respiratory function. As many patients may receive their first dose of epidural opiate either during anaesthesia or in the early recovery phase, such an interaction may be clinically important. This randomized, prospective, double-blind study was designed to assess the effect of epidural sufentanil on early respiratory depression when administered to intubated spontaneously breathing patients under general anaesthesia in combination with epidural lidocaine and epinephrine, and to study the duration of postoperative analgesia. Methods Forty ASA I or II patients for elective total abdominal hysterectomy were studied, using a combination of epidural and light general anaesthesia. The study was approved by the University of Cape Town Ethics Committee and informed written consent was obtained. Preoperatively, random allocation of patients into two groups, using tables of random numbers, was made in the pharmacy where sterile, preservative-free opiate solutions were prepared. There were 20 patients in each group. All patients received a premedication of 20 mg temazepam orally, two hours preoperatively. An intravenous infusion was established prior to epidural insertion, and 15 ml. kg-1 of a balanced electrolyte solution were administered. Immediately preoperatively, an epidural catheter was inserted by one of the investigators at the L2,3 level, using the loss of resistance technique. All patients received sequential doses of lidocaine 1.5% with epinephrine 1/200 000 until sensory blockade to the T 4 level was established. Sensory block was assessed by cold sensitivity and motor block according to the Bromage criteria, s Anaesthesia was induced with etomidate (given to loss of eyelash reflex) and tracheal intubation was facilitated with succinylcholine 1 mg. kg-j following topical spray with lidocaine 4%. Maintenance of anaesthesia was with 65%
221 nitrous oxide in oxygen, and enflurane 1.5-2%. After ten minutes of spontaneous breathing following recovery from succinylcholine, patients in Group 1 received 50 I~g sufentanil in 10 ml normal saline with 1/200000 epinephrine and Group 2 patients (control) were given 10 ml normal saline with 1/200 000 epinephrine epidurally. All anaesthetics and observations were performed by the authors. Patient monitoring included continuous ECG, noninvasive blood pressure measurement at three-minute intervals using a Dinamap (Critikon), end-tidal PCO 2 measurement using a pre-calibrated capnograph, tidal volume recordings on a Wright respirometer, haemoglobin saturation by pulse oximetry, and serial arterial blood gases via a 22-gauge catheter in the radial artery of the nondominant hand. Baseline recordings prior to administration of the epidural opiate included heart rate, blood pressure, tidal volume, end-tidal PCO 2 and arterial blood gases. All measurements except blood gases were performed at five minutes after the administration of sufentanil. Subsequently recordings were made of all indices every ten minutes for the first hour, then every 30 min until enflurane was discontinued. Glycopyrollate 0.4 mg was administered intravenously if heart rate decreased to
